Pathology/Lab Coding Alert

Question: Our pathologist received 13 colon biopsy specimens from a follow-up colonoscopy for a patient with a diagnosis of ulcerative colitis. He also performed a GMS stain on one of the biopsies. We billed 88305x13 and 88312, but were denied payment for the biopsies. Is this due to a policy regarding maximum number of units?

Virginia Subscriber

Answer: With proper documentation of 13 distinct colon biopsy specimens, you should be able to bill 13 units of 88305 ((Level IV - Surgical pathology, gross and microscopic examination, Colon, biopsy).

Although CMS has published a table of codes with unit limits under the Medically Unlikely Edits (MUE) program, it appears that CMS has not released all MUEs. Reports within the industry suggest that such a limit might be in place for some pathology codes, including 88305.

Do this: Contact your Medicare contractor to get an explanation of why the claim was denied. See if you can appeal the denial using appropriate methods such as a modifier like 59 (Distinct procedural service) and providing additional documentation to support medical necessity for the 13 biopsies.